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Project Plan 1 Projektplan för ansökan om forskningsfinansiering från Kampradstiftelsen 2017. Huvudsökande: Carl Bo- nander, Karlstads universitet. Medsökande: Johanna Gustavsson, Karlstads universitet och Mikael Svens- son, Göteborgs universitet. Project plan 1. Purpose of the project This project aims to evaluate an intervention designed to reduce the incidence of fall-related inju- ries and increase mobility among elderly populations during the winter. In Sweden, 11 250 pedes- trians older than 65 years of age annually seek emergency medical attention after fall accidents, 3300 of which are caused by slips due to snow and ice (Schyllander 2014). Many older individuals, especially women, experience a fear of falling which may inhibit their physical activity and mobil- ity in ways that negatively impacts their mental and physical health (Scheffer et al., 2008). This fear increases during the winter months due to the increased slipperiness caused by snow and ice, in which an increased risk of falling poses a limitation to the outdoor, active mobility of elderly populations during colder periods (Pohl et al., 2015). The burden on emergency departments also increases sharply during these months due to the spike in fall-related injuries that follows with colder temperatures and snowy weather (Gyllencreutz, Björnstig, Rolfsman, & Saveman, 2015). In our proposed project, we aim to take a more detailed look at a societal intervention that has begun to spread across Swedish municipalities, in which some municipalities have taken effort to distribute studded footwear to their elderly residents, free of charge. Using a mixed methods-ap- proach (i.e. mixing both quantitative and qualitative analyses), we hope to answer a range of so- cially relevant research questions that may help policy makers, as well as the public, to make in- formed decisions regarding such interventions. Specifically, these questions are: Q1: How do elderly persons perceive risks as pedestrians? How do they experience the need for, use of, and designing of studded footwear? Does the use of studded footwear allow them to be more active during the winter? Which factors can optimize compliance with municipal studded footwear interventions? Q2: What can be learned from the implementation process in municipalities that have im- plemented free studded footwear programs? Q3: What are the population-level effects on pedestrian fall-injuries in municipalities that have distributed studded footwear? Q4: Are the efforts cost-effective? 2. Expected results and societal relevance Our expectation is that the results from this project, whatever they show in the end, will be useful to municipal decision-makers and practitioners working with safety among the community-dwell- ing elderly. If we find strong evidence that the studded footwear programs are cost-effective, we will be able to make recommendations on large-scale implementation and optimization of such programs. If not, we hope that our qualitative studies will uncover areas for improvement and modification so that they can reach a higher level of effectiveness in preventing fall-related injuries while increasing the winter-time mobility of the elderly population. 1 Projektplan för ansökan om forskningsfinansiering från Kampradstiftelsen 2017. Huvudsökande: Carl Bo- nander, Karlstads universitet. Medsökande: Johanna Gustavsson, Karlstads universitet och Mikael Svens- son, Göteborgs universitet. 3. Communication plan We will, alongside the scientific publications that the project generates, communicate the results using press releases via the University’s communications office. We will also communicate the results directly to relevant elderly organizations (e.g. the Swedish National Pensioners’ Organisa- tion, PRO) as well as Sveriges Kommuner och Landsting (SKL) and Trafikverket, which we hope means that our results will reach our two target populations: (1) the community-dwelling elderly and (2) municipal decision-makers and practitioners involved in elderly and/or pedestrian safety. Preliminary results from Gothenburg, based on Holmberg (2017), have already been presented by Holmberg & Bonander at SKL:s Trafik- och gatudagar in Stockholm on the 16th of October, 2017. 4. Collaboration with other universities and actors This is a joint project that will be conducted primarily at the Center for Public Safety at Karlstad University together with the Health Metrics Unit at the Sahlgrenska Academy, University of Gothenburg. We have been in contact with PRO in order to validate its importance of this project to the elderly community. We will continue to maintain this contact throughout the project in or- der to make sure that our efforts are in line with societal needs. We will also work closely with practitioners at the municipalities that offer free studded footwear programs to make sure that all organizational aspects are covered and fully understood by our team. 5. Project team Providing valid answers to the questions posed as a part of this project requires an interdiscipli- nary team of researchers with experience in epidemiology, nursing and health economics. Our budgetary plan includes funding for one doctoral student (ending with a two-year licentiate de- gree) with a specialization in elderly health, causal inference and health economics, who will do a majority of the work as part of his/her licentiate thesis. Supervising this student will be a joint effort by researchers at the Centre for Public Safety, Karlstad University (Carl Bonander, Ph.D., specializes in causal inference and epidemiology; Johanna Gustavsson, Ph. Lic., who specializes in elderly safety and nursing care), as well as the Health Metrics unit at the University of Gothen- burg (Mikael Svensson, Professor/Ph.D, who specializes in health economics). Both environments offer a promising research setting for the project team. The Centre for Public Safety (CPS, www.kau.se/cps) at Karlstad University is a research center that aims to facilitate interdisciplinary research within the fields of injury epidemiology and soci- etal safety. Current and past research projects and dissertations produced by the team at CPS, which includes researchers from both the health and social sciences, involve many topics and methodological approaches relevant to the current project. For instance, we have produced two theses that focus specifically on elderly health and falls (Nilson, 2014; Gustavsson, 2015), and one thesis that focuses on causal inference in policy evaluation of injury-related interventions (Bonan- der, 2016). We have a close relationship with Trafikverket, who is currently funding a research program at CPS (The Vision Zero Academy), including a postdoctoral fellow that focuses specifi- cally on implementation science in the context of the Swedish Vision Zero policy for road traffic injuries and its sister policies in other sectors. We also collaborate with Professor Per Nilsen, the director at the Lifestyle Intervention Implementation Research Group at Linköping University, in several projects. Hence, we are well equipped to provide a good research environment for a doc- toral student with a focus on elderly health and policy evaluation. We will also be able to share insights and consult with many of these contacts during the course of the project. 2 Projektplan för ansökan om forskningsfinansiering från Kampradstiftelsen 2017. Huvudsökande: Carl Bo- nander, Karlstads universitet. Medsökande: Johanna Gustavsson, Karlstads universitet och Mikael Svens- son, Göteborgs universitet. The Health Metrics unit at the University of Gothenburg (www.healthmetrics.gu.se) consists of a multidisciplinary team of statisticians, health economists and epidemiologists that work on a wide range of methodological issues related to health statistics and economic evaluation of health in- terventions. Professor Svensson has supervised several doctoral students with a focus on health economic evaluation methods and applied cost-effectiveness studies and has published the re- search in leading health economics and evaluation journals. The Health Metrics unit also has a strong applied statistics research program, and several of the senior researchers from that pro- gram will be part of this project in an extended network and as potential mentors. 6. Originality of the project Some small-scale studies exist on the effects of studded footwear on friction and safety (Berggård & Johansson, 2010; Gard & Berggård, 2006; McKiernan, 2005), but none have investigated the implementation and impact of free studded footwear programs. One master thesis conducted by Robin Holmberg under the supervision of Carl Bonander (principal investigator for this project) studied the impact of a free studded footwear program for the elderly population in Gothenburg (Holmberg, 2017). Using a quasi-experimental method and injury data from emergency depart- ments, Holmberg was able to demonstrate a significant reduction in fall-related injuries due to slipping on snow and ice after the implementation of the program in 2013. This study sparked our interest for continued research into these programs, and it still remains to be answered whether or not these results can be replicated in other municipalities that have implemented these pro- grams. We also, as the research questions stated above indicate, aim to delve deeper into the qual- itative aspects of the intervention by performing interview studies with elderly people in similar municipalities, as well as conducting cost-effectiveness analyses. Hence, we believe
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